Ever since the founding of our Republic during the Revolution, persons from all walks of life have agreed to serve in the military during periods of national mobilization. They have done so with the realization that they could be killed or injured during the ensuing conflict. Their patriotic actions create an implicit compact between each of them and our society. Clearly, our society owes each of these citizens a great debt of gratitude for their contributions. If they have been killed, we also incur an obligation to their families; if they have been injured, we also incur an obligation to address their health problems. As an honorable people, we must fulfill this compact with those who have served on our behalf.

Yet, there are important lessons in our recent history that we must heed.  Those who served for us in the Vietnam Conflict were neither welcomed home nor cared for very well, particularly when they experienced the psychological wounds of war. From that very unfortunate period of our history, we have learned the importance of welcoming all veterans home, which we have done very well for those returning from Iraq and Afghanistan. However, we still have major difficulties in addressing the psychological wounds of those who have served on our behalf in these continuing conflicts.

Those who served in Vietnam were required to complete only a single duty tour of 12 months. Thus, their service had very clear beginning and ending points. For those who have served in Iraq or Afghanistan, it has not been uncommon to be deployed on 4 or 5 separate tours over the past 10 years. The long-term uncertainty of the continuing risk of death or injury coupled with the daily threat of death or traumatic brain injury (TBI) from an improvised explosive device (IED) has produced a very large number of psychological casualties in Iraq and Afghanistan.

The Department of Defense itself estimates that from 20 to 40 percent of those who actually have served in Iraq or Afghanistan (“boots on the ground”) have TBIs, post traumatic stress disorders (PTSD), other psychological conditions, such as depression or anxiety, or substance use conditions, such as problems with alcohol or prescription or illicit drugs.  These are very, very disturbing numbers. Translated, they mean that 300 to 600 thousand of the 1.5 million who have served in these conflicts over the past 10 years are returning to our shores with these problems.

These psychological wounds have many serious adverse consequences. Today, the US Army is experiencing the largest suicide rate in its entire history. Further, when veterans return home with psychological wounds, they frequently have great difficulty in adjusting to civilian life. Many develop family problems, sometimes including violence in the home and divorce; many are unable to find or hold civilian jobs; and many remain disconnected from their own communities. Because a majority of our current veterans originate in rural communities that are at or near the poverty level, community resources frequently are not available or adequate to provide support to these veterans and their families.

Clearly, the Department of Veterans Affairs is unprepared to deal with this problem. First, numbers this large simply overwhelm the capacity of the VA system. Second, VA hospital and outpatient clinics are located principally in urban areas as a consequence of the distribution of World War II veterans. However, most veterans from Iraq and Afghanistan are from rural areas, particularly in the South. An indicator of the problems currently faced by the VA is the fact that it currently has a backlog of more than 750 thousand veterans who are seeking disability benefits.

We must recognize that an urgent need exists to develop new solutions to address the psychological needs of our returning veterans and their families. One very promising avenue is the development of service contracts from the VA to county mental health and substance use programs to provide needed services in a timely way. Clearly, current VA contracting practices will need to be modified to make this possible.

If we are to continue to ask persons to serve in the military on a voluntary basis, as we have done since the end of the Vietnam Conflict, they must have the assurance that America will fulfill our implicit compact with them when they are killed or injured. Right now, that is not occurring.

Ron Manderscheid, PhD is the Executive Director of the National Association of County Behavioral Health & Developmental Disability Directors